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The Psychotic Patient
When considering the psychotic patient in the hospitalized setting, it is helpful to recall that while psychosis is a characteristic of some psychiatric disorders (e.g., schizophrenia, schizoaffective disorder, mood disorders with psychotic features), not every patient with psychosis has a primary psychiatric condition: indeed, psychosis is a general descriptive term for a phenomenon that may be present in multiple medical and substance-related conditions, many of them life-threatening, in addition to psychiatric disorders. Patients with psychosis can present with a broad range of signs and symptoms that may include hallucinations or other misperceptions, delusions, disorganized or illogical speech and thinking, blunted or inappropriate emotional expression, difficulties with self-care, behavioral disturbances, and sometimes agitation or aggression. Because there are many etiologies for psychosis, your role is to help determine the cause of the psychosis (medical illness, substance- or drug-related, or psychiatric) and to provide a management strategy to the referring physician.
Phone call
Questions
- 1.
What specific behavior is the patient exhibiting at this time?
- 2.
Is the patient physically agitated, behaving aggressively, or making threats to harm himself or herself or to others?
- 3.
When did the symptoms begin?
- 4.
What are the reasons for hospitalization?
- 5.
What are the patient’s medical illnesses?
- 6.
What medications is the patient taking, and have there been any recent changes?
- 7.
Have there been any recent changes in the level of arousal or any episodes of confusion or disorientation?
- 8.
Does the patient have a history of psychotic episodes or any known psychiatric history?
- 9.
Does the patient have a history of substance use?
- 10.
What are the patient’s vital signs?
Orders
- 1.
Order the appropriate level of monitoring for the situation. Remember that behavior associated with psychosis is very unpredictable. One-to-one observation may be necessary until you can assess the situation personally.
- 2.
If the patient is reported to be extremely agitated or behaving dangerously, you should consider ordering an as-needed medication such as an antipsychotic or a benzodiazepine to optimize the safety of the patient and those caring for him or her and to be able to safely perform an assessment.
- 3.
In the case of behavior acutely dangerous to either the patient or others, you need to personally evaluate the situation before verbally ordering the nurse to implement physical restraints or seclusion. (Most institutions have their own protocols for restraint and seclusion and for the assistance of hospital security. You should be familiar with these procedures and consider their implementation.) This makes seeing the patient a priority and something to be done immediately.
Inform RN
“Will arrive in … minutes.”
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